Author: Daniel Castellano

8 Ways to Reduce Health Care Costs

Currently, most discussion in the United States regarding health care reform is focused on the extent to which health care costs are covered by public or private insurance. However, it will make little difference whether health care is funded privately or publicly if the cost of health care is not held in check. Even with the current predominantly privatized system, the federal budget will be overwhelmed in a few decades by Medicare outlays, which are rising much faster than inflation due to increased health care costs. If the government will not be able to afford paying for health care for seniors, it will hardly be able to provide it for others. Our energies would be better directed, therefore, at reducing the cost of health care.

There are several ways that we can reduce health care costs almost immediately; others will take more time. These approaches are primarily directed at undoing the antiquated system of medical education and hospital regulation, much of which is grounded in the politics of the 1930s. Supposedly non-profit hospitals and universities are able to gouge the public for their services, yet receive federal subsidies. It would be considered abominable if a non-profit charity or church indulged in the extravagances of these institutions, many of which have billion-dollar endowments. Anyone who has seen an $8000 bill for routine testing or a night’s hospital stay should know that the major culprits behind health care cost are the service providers, not the insurance companies.

Indeed, the oft-maligned HMOs are themselves the product of the last great effort at liberal health care reform, the HMO Act of 1973. Prior to the HMO act, most health insurance only covered major illnesses or surgeries, just as auto insurance only covers accidents, not routine maintenance. Ordinary care could be paid out of pocket, or in the cases of the extremely poor, not at all. This was not burdensome, since the cost of a routine doctor’s visit was not much. With the advent of mandatory employer health insurance, much more extensive coverage was required, driving up the cost of insurance premiums. Further, since the patient no longer paid for routine health care out of pocket (except a fixed co-payment), he did not care what exorbitant fee the hospital charged the insurance company. Since patients no longer had any incentive to keep costs down, and indeed were often unaware of the price, the cost of health care could rise, and the insurance companies would pass on this cost in their premiums.

Going further back, our medical education system has relied on a bizarre system of requiring four years of medical school in addition to university, and then three or four years of grossly underpaid internship or “residency”, after which the young doctor emerges with staggering debts often well over $100,000. Given this burden of education and debt, it is no wonder that a large proportion of American doctors choose to become high-priced specialists, leaving a deficiency of general practitioners. Only the extremely intelligent can pass the rigors of U.S. medical schools, where emphasis is placed on the mathematical and analytical aspects of medicine, and less on preventive nutrition and humanitarian aspects. The typical medical school student is intellectually overqualified to be a GP; many highly competent doctors in other countries would not pass muster in U.S. schools, even though experience proves they are quite capable in their profession.

Nurses possess the education necessary to diagnose and treat most common ailments; and pharmacists have the education to prescribe medications, yet both are prohibited from exercising their craft due to our arcane medical system that requires an MD to be involved in every diagnosis and treatment. Given that this same system induces a shortage of GPs, this can only drive up cost. What is worse, these science-oriented, non-humanitarian doctors tend to think everything is to be solved with expensive testing and drugs, especially since ordering tests and drugs takes less of their time than getting to know the patient and his behavior. I once had an “old school” doctor who resigned out of disgust with the increasing pressure to become a pill dispenser.

The residency program, which is supposed to be a time of apprenticeship, is often just an opportunity for the hospitals to exploit cheap labor. Residents often work 100 hours a week, with little sleep, thereby impairing performance, and much of their time is spent on menial administrative tasks unrelated to patient treatment. With yet another three years of lost income, it is no wonder that they all wish to cash in on a high-paying position. To cover their increased debt, they will actually have to be paid more than if they had been paid justly in the first place.

In sum, I propose the following cost-cutting measures:

  1. Abolish Direct-to-Consumer (DTC) advertising for prescription drugs, as this was illegal before the 1990s, and consumers (not to mention doctors) are often poor judges of what medications they should take. Billions of dollars would be saved from this act, since the cost of TV advertising would no longer need to be built into drug costs.
  2. Reform the residency program so interns have the right to demand competitive salaries and reasonable hours. Increasing their salaries should actually lower costs in the long run, as doctors will begin their careers less debt-laden.
  3. Allow RNs and pharmacists to diagnose and treat ailments within their competency. This will reduce costs, as they have lower salaries.
  4. Reduce the cost of medical school (by student grants) or allow admission to medical school direct from high school. Less stringent mathematical requirements should apply to GPs, as mathematical geniuses don’t necessarily make better family doctors. A certain amount of scientific hubris would have to be swallowed here.
  5. Set limits on tort claims related to medical malpractice. This will lower malpractice insurance premiums, greatly reducing the salary demands of doctors.
  6. Stress preventive medicine in medical education, including nutrition and exercise. Less emphasis on surgery, drugs, and high-tech testing as solutions to preventable diseases will greatly reduce costs.
  7. Require full advance disclosure of costs to the patient. Often the patient does not know or care what the cost is, allowing gouging by the hospitals. Ideally, insurance should not cover routine care, which would force caregivers to drive down their prices in order to be competitive among consumers. Emergency care should be price-regulated, since the patient often has no choice of caregiver in such a situation.
  8. The government could demand more stringent accounting from hospitals and universities to account for their non-profit status. If the institution is federally funded, salaries derived from ordinary revenue should be held to the federal executive pay limit. Alternatively, abolish their non-profit status, and dispense with the myth that hospitals and universities are not just businesses.

Mushroom Clouds and Moral Mediocrity

Leave it to a comedian to state plainly that Truman’s use of atomic weapons was a war crime, only to backpedal out of political expediency faster than you can say Arlen Specter. This short-lived moment of lucidity has occasioned a lively discussion on the topic, by no means confined to the political left. Although many paleoconservatives in Truman’s day and beyond expressed horror at the bombing of Hiroshima and Nagasaki, conservative opinion today generally favors nationalism over morality, and we are invited to examine the supposed moral complexity of the issue. In today’s political right, only a few social conservatives and libertarians are willing to state the obvious moral truth that mass incineration of civilians is not justified by military expediency.

It would be easy to argue that the callousness of mainstream conservatives toward the rights of foreign prisoners and noncombatants is a major cause of its recent decline in popularity. It would also be wrong. Sadly, most Americans are willing to hedge basic moral principles for the sake of security. To the chagrin of the liberal news media, a majority of Americans polled in favor of the recent NSA phone surveillance program, even well after details of the program were leaked by the press. A strong majority of the public has supported keeping the Guantanamo prison open, and slim majorities have favored the use of waterboarding and other harsh interrogation tactics. As for pre-emptive wars of choice, public support of the Iraq war from 2003 to 2007 closely matched the perception that the war was going well. It would seem that we support illegal wars in the short term as long as we appear to be winning, though the perceived success of the 2007-08 surge did not restore the war’s popularity.

Unprincipled compromise of moral values can be found even among academics, who are supposedly more thoughtful. Although the vast majority of American historians are politically liberal, their vaunted concern for human rights diminishes when discussing Truman’s use of the atom bomb. Indeed, the man who wiped out two cities and later led the nation into the disastrous Korean War is cited by most historians as an example of an unpopular president who was later vindicated by history. This supposed vindication consists only in the approval of liberal historians, who are evidently as prone to place partisanship over principle as their conservative counterparts. We can only imagine what they would write if a Republican had dropped the bomb.

The general coarsening of morality, even among the educated and among those who claim to preserve traditional social values, is a worrisome development. Some paleoconservatives such as Pat Buchanan have adduced from this reality that the left has won the culture war, through their domination of academia and the entertainment media that shape public opinion. Those who would defend the classical virtues must find themselves in a constant struggle against societal tendencies, and they must risk ostracism and ridicule for merely holding what has been held by practically all the great moral philosophers in history. The tyranny of the majority of which Tocqueville warned is evinced in the perception that the rectitude of same-sex “marriage” can be determined by persuasion of the majority. The majority, as we know, is notoriously fickle. Fifteen years ago, even liberals shrank from same-sex “marriage”; now, the propaganda machine would like to portray any opponent of such unions as a Neanderthal.

All too often, shifts in opinion on moral matters (and associated historical, sociological and anthropological judgments) hinge upon nothing more than emotion and propaganda. A thing becomes right or wrong simply because the current majority says it is. Such a hermeneutic is utterly unworthy of an adult human being, yet democratic culture makes it seem natural. Few even among the paleocons will go so far as to identify democracy as the root of moral relativism. Most have held some form of the naive view that the majority would freely accept virtue if only it were presented to them clearly. In actual experience, the morality of the masses, when uncoerced, gravitates toward mediocrity. We can see this with the gradual shedding of social constraints and the coarsening of mores over the last forty years. This coarsening is expressed in dress, diction, and bearing, as well as more quantifiable sociological phenomena. On the Internet, the more popular sites invariably attract cruder and more degenerate discourse. While democracy romanticizes the virtue of the masses, reality teaches that we can hardly expect great virtue from a people fed a steady diet of mind-numbing television and Twittering.

The ancient Athenians recognized that democracy, or indeed any form of government, could work only if it was governed by laws, which they called nomoi. The nomoi were not the acts of a legislature, but basic moral precepts that defined the legal principles of society. Even the popular assembly did not presume to have direct authority to change the nomoi, though they sometimes appointed a committee of jurists to recommend additions to the laws. Even this limited power was too much in the eyes of Plato and Aristotle, who emphasized that nomoi, especially those that are unwritten, must bind even the people as a whole. For this reason, they posited the necessity of founding a polity with a lawgiver such as Solon, a man (or men) of eminent ability, whose superior wisdom would establish basic laws that are better standards than most would choose for themselves.

When basic moral principles are considered immutable, or at least not subject to popular sovereignty, the nomoi rule, and people only implement them. They are to be amended only after grave circumspection by the most competent men. The basic morality of society as a whole is shaped in large part by the excellence of the lawgiver. If, on the other hand, people are given full sovereignty even over right and wrong, we will invariably gravitate toward social mores that reflect the moral mediocrity of the majority. Few would work if there was no need, and few would strive for excellence unless they were constrained to do so. We should expect a society just moral enough to keep the economy functioning, and indeed we increasingly expect our statesmen to be little more than business managers.

When a political or religious institution commits some crime, demagogues like to say that the institution has lost its moral authority or credibility. What, then, shall we say about the moral authority of the masses? Most of the great crimes of powerful institutions were committed with popular consent, and even when the people are sovereign, they seem to be unable to discern whether it is moral to exterminate hundreds of thousands of unarmed people, or to invade a nation without provocation. Given this dismal track record, I should not like to entrust any of our civilization’s most revered values to the whims of popular sovereignty. To quote Horace, Quid leges sine moribus vanae proficiunt? Modern political society seeks in vain its salvation through statutes and policies, as long it pursues moral mediocrity. The notion that the people are sovereign even over morals has led to the enshrinement of our baser instincts as rights. Those on the political left wallow in the sins of eros while those on the right commit those of thanatos. If society exists for something more than the fulfillment of animal impulse, it ought to strive for something better than the natural human condition.

A Behavioral Approach to Social Disease

Criticism of Pope Benedict’s recent remark on the effectiveness of prophylactics fails to distinguish between the moral and physical aspects of using such devices. As the supreme teaching authority of the Catholic Church, the Roman pontiff is concerned mainly with the moral aspect of venereal disease transmission. Condom usage fails to address the moral cause of sexually transmitted disease – namely, promiscuity – and indeed may encourage it by creating a false sense of security. In this sense, prophylactics are not a solution to the problem, but may even exacerbate the problem.

Many commentators have misconstrued the Pope’s statement as making the untenable assertion that condoms are physically ineffective. While it is unquestionable that prophylactic devices significantly reduce the chance of infection, there are sound statistical reasons for doubting their ability to contain epidemics. We will examine these reasons briefly, to show that condoms, to some extent, fail as a solution to the STD problem even in a physical sense.

According to the FDA, when condoms are used properly and consistently, the rate of pregancy in one year is 3%. Based on actual use, with human error and negligence, the pregnancy rate with condoms is 14% in one year. Without protection, the pregancy rate is 85%, so the figures cited reflect condom failures in 3.5% of optimal users and 16% of actual users in a given year. However, we must also consider that those who became pregnant likely had multiple failures in that year, since it is difficult to become pregnant on the first attempt. Even with optimal fertility (25%) it typically takes 4 months, so those who became pregnant likely had 4 or more failures per year. Assuming a Poisson distribution of failures, this means there’s an average of 1.25 failures per year with optimal usage, or 2.25 failures per year based on actual usage.

Again using Poisson statistics, I compute from the above that the chance of one or more failures per year is over 70% based on optimal usage, and nearly 90% based on actual usage. Based on the U.S. average of 58 acts of intercourse per year, there is a 2% failure rate per act with optimal usage, and a nearly 4% failure rate with actual usage. These results are consistent with other studies showing that condoms slip off completely 1-5% of the time.

In a society where the prevalence of STD is low, the failure rate of prophylactics is low enough to provide adequate protection, since it is improbable that a failure will occur while with an infected partner. However, in many African countries, the prevalence of AIDS and other STDs is in the range of 10-20%. This makes it a statistical near-certainty that a person will acquire that disease in a decade or so, if partners are changed constantly, even if condoms are used properly and consistently. Thus condoms are not an effective solution to the STD problem in high-prevalence areas like Sub-Saharan Africa.

People can minimize their risk even in high-prevalence areas by remaining monogamous with a partner who is known to be uninfected. In this scenario, multiple prophylactic failures pose little or no additional STD risk. A promiscuous person, by contrast, is exposed to the full risk of the high prevalence rate in the general population. This risk can be reduced by having one’s partner tested in advance, but the clandestine and spontaneous nature of promiscuous encounters operates against the likelihood of such precaution.

These theoretical expectations are corroborated to an extent by the actual epidemiology of STDs. In the United States, more than 50% of AIDS cases are among homosexual males, a tiny subgroup (3% of men or 1.5% of adults) where extreme promiscuity is common, and having as many as 100 partners per year is not rare. More than half of all syphilis cases in the U.S. are in the South, particularly among blacks, where promiscuity among the youth is rampant, and 48% of black women aged 14-19 have an STD. Still, in most cases, the prevalence of disease is low enough for prophylactic use to contain its spread. Such is not the case in Africa, where adultery and prostitution are practiced with much greater frequency than in the West, enabling AIDS to become an epidemic in the heterosexual population.

The relationship between behavior and epidemiology is not always straightforward. For example, in the United States there was an eightfold increase in genital warts in females from the early 1950s to the late 1970s (rising from 13 to 106 per 100,000). Gonorrhea incidence rose to epidemic proportions in the 1970s and 1980s. These changes are generally attributed to the liberalization of sexual attitudes, leading to greater promiscuity. However, an infectious disease is caused by an organism, so it may be influenced by biological factors, as seems to be the case with the gradual decline of gonorrhea in Europe and Israel since 1970, as well as its resurgence in the late 1990s.

Still, the ability to contain STD transmission through the usual means of prophylactics seems ineffective in the long run when not accompanied by more fundamental changes in behavior. In the U.S., where condoms and sex education have been ubiquitous for decades, 65 million people have viral STDs. (American Social Health Association (1998), “Sexually transmitted diseases in America: How many cases and at what cost?”) Over 50 million of these have genital herpes (Fleming DT et al. (1997), “Herpes simplex virus type 2 in the United States, 1976–1994,” New England Journal of Medicine, 337, 1105–1111. NIAID estimates range from 45-60 million.) Considering the entire U.S. population aged 14 and over is 242.9 million (in 2006), this means about 27% of the postpubescent population has a viral STD, and 21% has herpes. If this is success, what does failure look like? Faced with these facts, only the hardhearted could deny that even a highly developed “safe sex” public policy is unable to contain STDs in the long run.

Indeed, with the prevalence of herpes exceeding 20% in the U.S., condoms can no longer serve as an effective means for containing the epidemic, because their failure rate is not low enough to stop the spread of the disease among promiscuous people. With an average of at least 1-2 failures per year even when used properly, it is only a matter of time before someone with multiple partners in an exposed community becomes infected. This is not to say that condoms are altogether ineffective, but they can only slow the epidemic, not stop its spread.

Emphasis on condom use rather than reforming behavior is predicated on the assumption that it is difficult or undesirable to get people to change their sexual behavior. However, the entire enterprise of promoting prophylactic use involves getting people to do precisely that. There is no reason in principle why the same educational effort could be applied to encouraging people to at least limit their number of partners, if they cannot be absolutely monogamous. When sexual disease is highly prevalent, it is utterly misleading to claim that promiscuous behavior is “safe sex” when condoms are used. Risk is best minimized by knowing one’s partner well, and limiting changes in partners as much as possible. While this should be obvious, it has not received due emphasis in public health education. This reticence may be grounded more in the liberal sexual morality of policy makers and educators than in sound reasoning.

It has been known for ages that promiscuity is at the root of “social diseases.” Historically, these diseases had been marginalized in Europe and her colonies, confined mainly to the indecent practitioners of prostitution, adultery and fornication. With the destigmatization of these practices, sexual disease has gone into the mainstream, and will likely remain there as long as people fail to maintain a salutary monogamy, or at least a very limited polygamy. Long-term monogamy or limited polygamy has been the dominant paradigm of most human cultures for good reason, and has survived the test of experience. It is bad policy not to discourage foolish behavior, and even worse to tacitly encourage it, by claiming that it can be made safe.

Modern Western medicine has become notoriously negligent in addressing the behavioral causes of disease (e.g., nutrition, exercise, sleep), and instead increasingly emphasizes the use of expensive drugs and devices to address maladies after the fact. We see the same approach with sexual diseases: the solution is in a device that can be bought and sold, rather than in correcting behavior, which costs nothing, but requires patience and a modest amount of discipline.

None of this implies that prophylactics play no role in solving the STD problem, for they do indeed reduce the rate of transmission. For this reason, many contend that it is injurious for religious organizations like the Catholic Church to oppose the use of contraceptives, and effectively encourage the spread of disease. However, the same religions that oppose contraceptives also condemn adultery, fornication, and prostitution in even harsher terms. It is hard to believe that there are people who would have no qualms about committing the major offenses of adultery, fornication or prostitution, yet scrupulously heed their church’s strict teaching against contraception while committing those acts. Those who flout their church’s teaching on marital fidelity will almost certainly have no scruples about using contraceptives.

This appears to be borne out by religious statistics: only 20% of nominal Catholics in the U.S. (1999) accept official Church teaching against contraception, which is consistently the least popular of any doctrine surveyed (even less so among youth), being held only by the most scrupulously orthodox. By contrast, 68% accept that a Catholic must have his marriage sanctioned by the Church. The idea that religious teaching against contraceptives encourages STDs rests on the fallacy of divorcing such injunctions from the context of their full sexual ethic. I have yet to hear of any Catholics who heed Humanae Vitae yet live promiscuously (if such a thing were possible), so I must dismiss this as a straw man.

The fallacious argument above is made possible by a stubborn refusal to acknowledge the association between promiscuity and venereal disease.
This is evident in educational propaganda, where even monogamous intercourse is depicted as unsafe if lacking a condom, while promiscuous acts with a condom are safe. This completely inverts the actual degree of statistical correlation, and is therefore antithetical to the facts. How will a monogamous person magically acquire an STD? If the spouse is covertly unfaithful, any disease contracted through adultery will be passed on anyway when the couple tries to conceive. Many health educators not only neglect, but studiously avoid making a correlation between promiscuity and STD. By giving the false assurance that condoms are effective protection for a promiscuous person when disease prevalence is high, such educators are effectively prescribing the disease that it is their duty to prevent, by encouraging the behavior that is at its root.